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Nursing Management:
doi: 10.1097/01.NUMA.0000363818.26100.d1
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Hardwiring process changes

Devore, Shelly RN, MSN, FACHE

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Shelly Devore is the executive director of the clinical workflow initiative at BJC Healthcare, St. Louis, Mo.

Beginning November 2006, BJC Healthcare embarked on a strategy to transform care delivery across eight community hospitals in the greater St. Louis, southern Illinois, and mid-Missouri regions. The strategy included many tenets from the Institute for Healthcare Improvement's Transforming Care at the Bedside framework: setting daily goals with the patient, including the patient in every care decision, conducting hand-off reports at the bedside, and more.1 The benefits of these changes were immediately clear, but so was the need to change numerous underlying processes, in many cases with the help of new clinical information technology (IT).

A common approach to installing IT is to redesign workflow during implementation, with system capabilities balanced by end user input. An even more common approach is to simply let IT dictate the new workflow. Too often, even the best intentions crumble under the weight of tight budgets and deadlines. The result can be suboptimized system use and a missed opportunity to transform care delivery. Management was intent on finding a better approach.

For 18 months, multidisciplinary teams examined current processes, defined ideal future states, and redesigned processes to meet those states. Only at that point did they begin to look for enabling solutions, including IT that had been purchased or developed in-house, other commercially available IT, and even not yet available IT. While coordinating such an initiative across a 1,000+ inpatient bed health system is complex, the same discipline can be applied to any community hospital.

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Case (study) in point

Beginning in November 2007, a team of process engineers and nurses went to all eight hospitals to document current state processes in all medical-surgical and ICU units. Lead by two Six Sigma master black belt professionals, the team used Lean Six Sigma methodologies such as flow sheets and process maps to identify which steps added value, which contributed to waste, and which created opportunities for harm.

Six months later, the team had identified six high-impact processes that needed the most work. Additional resources were then recruited so a dedicated team could be assigned to each process. Each team included a chief nurse executive, who served as team champion; a clinical process leader (nurse, pharmacist, or social worker); a Lean Six Sigma black belt; a project manager; and the remaining members selected for their subject matter expertise. Design sessions included physicians and patients. After any redesign, clinicians reviewed the new process.

Suggestions for changes were incorporated into the final design. Despite the facility-specific input, the six redesigned processes will be rolled out uniformly across all campuses. The following process descriptions reflect progress to date.

Admission history and assessment. This team is examining all data points collected during the patient assessment to see if they're necessary. Too often in this profession, we gather data we don't need just because we've always done it. With the new process, each data point will be linked to a regulation or need. Using the charting by exception framework, nurses will only document the absolute minimum required. The time saved can then be used to meet their patients' psychosocial and educational needs.

Care coordination process. This team is taking a hard look at the current care planning process, which is largely irrelevant to physicians, patients, and even most nurses. If care planning is going to be required, it must be intentional and beneficial to everyone involved, especially patients. Today's care planning process focuses not on meeting patient needs but on regulatory requirements. For example, as officially recognized nursing languages, NIC, NOC, and NANDA standards have many benefits, but they don't fit within the patient-centered, multidisciplinary culture defined at the BJC community of hospitals. How, then, can the plan of care be redesigned to cover everything staff must do to ensure the patient is discharged in a better state, based on diagnosis and the patient's own goals? How can it be both written in the patient's language and useful for all clinicians?

Discharge planning. Well-coordinated care means everyone is working toward the same discharge day. Too often the physician has one day in mind, the case manager another day, and the nurse yet another. The biggest delay is often in completing the patient and family education. Patients may be disoriented during and after a hospital stay, and family members may be overwhelmed. To best equip patients to manage their own healthcare, education must occur throughout the entire stay. By not leaving this crucial step until the last minute, care teams are much more likely to meet discharge goal times.

Bar code medication administration. This team is focused on making sure nurses cover the “five rights” without including any wasted steps. How can we eliminate the queue waiting to get medications from the automated dispensing cabinets? How can we discourage bar code medication administration workarounds if scanners don't always scan? Finally, how can we guarantee that the medication management process—from ordering to dispensing to administering to documenting—is seamless and safe?

Order management. BJC is just beginning its journey to computerized provider order entry. To prepare, this team is redesigning the ordering process, from the time the order is written to the time it's completed and resulted. In the current (oversimplified) state, a physician will write the order, which sits until it can be confirmed and carried out. Once the test is completed, someone must wait by a fax machine for results so that someone else can take action. Performing each step more efficiently may not only eliminate many opportunities for harm but also shorten the length of stay.

Bed and resource management. This team is looking at how to ensure the right staff members, with the right competencies, are taking care of the right patients in the right units. In the current state, patients often wait in the ED for a bed because bed controllers don't know where beds are available. Sometimes beds are “hidden” and sometimes they're not staffed. In the ideal state, everyone will know where there are available beds, and all available beds will be appropriately staffed.

To design each future state, the teams brought in end users to walk through the current state and identify which steps could be eliminated. Some groups were able to decrease steps by 40%. For example, the medication administration process went from 55 to 22 steps in the ideal state. Even if the implemented process requires 30 steps, shooting for the ideal state ensures the organization pushes itself and the vendor. Plus, the end users who participated in the design sessions can't wait to see the new process in place. How often do frontline nurses express enthusiasm for change?

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Scouring the market

As the redesign phase draws to a close, attention has turned to scouting the market for solutions that support the new processes. While that involves some shopping, it also entails visiting other facilities that are using IT to support similar processes, with good results and high user satisfaction. The teams are also looking at ways to adapt currently installed IT as well as pending technology the organization has purchased but not yet installed. This will ensure implementations are tailored to accommodate the new workflows and not vice versa.

For example, patient rooms in the newer facilities feature touch screens attached to ceiling-mounted booms so they can be swiveled at the bedside. Currently patients use the technology to access the Internet, watch patient education videos, and make meal selections. In redesigning the care coordination process, the team proposed using the touch screens to share the full care plan, written in plain language, with the patient and family.

The discharge process team looked at how the touch screens could be used to streamline patient education. What if all of the educational materials were uploaded, and the nurse could order the items the patient had to review based on the discharge plan through the clinical documentation system? Those items would then appear on the patient's screen, with instructions to review them and click at the end of each topic to confirm that he or she understood the content, or to review it again. When the patient completed all ordered items, the system would auto-document for the nurse that education requirements had been completed.

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Keys to success

Implementations that support the new processes are slated for 2010, with the first measurable results by the end of the year. Eighteen months into the initiative, however, project leaders have several takeaways: —Governance is critical. Involve the chief executive officer, one or more physician champions, the chief nursing executive, and the chief information officer. —For each team, include a Lean Six Sigma (or similar methodology) black belt, a project manager, and clinicians with a process improvement bent. If you don't have black belt personnel or project managers on staff, use a consulting firm.

—Allow at least 6 months to assemble your teams and for managers to backfill vacated positions. When designing your future state, you want your best people, so their absence will be felt. For this eight-hospital initiative, 32 top performers have been reassigned for several years. A smaller facility may want to recruit three to four people, who will stay on the job long past implementation to help measure and sustain results. —Convene physicians, patients, and staff in the same room to discuss both current and future states. It will be eye-opening for them to hear each other's view.

BJC began this journey well before the economic downturn. Funding an effort that wouldn't return quantifiable results for at least 18 months meant executives had to take a calculated risk, but a strong commitment to quality guided their decision. The alternative? Investing in IT without redesigning processes first, virtually guaranteeing suboptimization and a lower return on investment. Take the time to do it right.

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Before you design, ask…

When redesigning processes, ask these questions:

1. Does this step bring value to the patient?

2. Does it meet a regulatory or other requirement?

3. If not, why are we doing it?

4. Could we eliminate it if we had some type of technology?

5. What might that technology look like?

6. Do we already own it?

7. Can we build or buy it?

8. Where can we see it in action?

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Reference


© 2009 by Lippincott Williams & Wilkins, Inc.

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